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Infection Control Statement


The Annual Statement will be produced annually and will include:

  • Significant events relating to infection control
  • Results of infection control risk assessments and its subsequent action plan
  • Results of the infection control audit and its subsequent action plan
  • A review of policies, procedures and guidelines

General Statement

The audit findings at Brook Medical Centre, Bradeley and Smallthorne sites, were of an overall good standard. many of the actions detailed below can be regularly re-assessed with an appropriate action plan put in place.

Significant Events

Needlestick injury

Risk Assessment

  • Annual Clinical Infection Control inspection at both Bradeley and Smallthorne sites.
  • Annual Sharps Box Audit
  • Annual Hand Hygiene Audit
  • Annual Personal Personal Protection Equipment (PPE) Items Check


The Annual Infection Control Audits were carried out in May 2019 by Harriet Shaw, Infection Control Lead, and Alyson Turner, Practice Manager. The main findings are detailed below, followed by actions taken:

  • An action plan has been formulated to outline all the relevant actions required from the annual inspection audit at Bradeley and Smallthorne sites. The main points highlighted are as follows:
    • Re-instate a cleaning checklist- schedule to be put in place for cleaning of clinical rooms for staff.
    • Aim to undertake more random inspections.
    • Ensure environments are clutter free with only relevant items in clinical areas.
    • Liaise with appropriate authorities regarding any requirements highlighted with maintenance/repairs.
    • Ordering of equipment as required.
    • For improvement / organisation of waste storage areas at both sites; potential to adopt locked cupboard space to house waste storage at Smallthorne site.
    • Highlighted that sharps boxes are not all assembled correctly and visibly dusty in treatment rooms – need to provide training to re-inforce policy to staff.
    • Practice to consider capital investment as required.
  • A Hand Hygiene Audit was undertaken in February/March 2019. Although not a 100% pass rate, all staff are well aware of hand hygiene policy and decontamination. In cases whereby all criteria were not met, education and advice was provided. For hand hygiene re-assessment this month. Improvements required are voiced at nurse meetings in order to try and urge compliance, thus indicating the importance of 100% achievement and that effective hand washing is widely acknowledged to be the single most important activity for reducing the spread of infection.
  • An audit was undertaken for a Personal Protection Equipment (PPE) Items Check. This mainly highlighted the need for a dedicated ‘Pandemic’ pack to be organised.
  • A Sharps Box audit was undertaken. This showed that the management of Sharps Boxes was of a good standard.
  • All staff will receive infection control training as part of their induction process. A staff induction pack is provided to all new starters, including information on infection control. Updates will take place annually in the form of online training as organised by Sara Pepper. Any interim education opportunities will take place in the nurse meetings monthly as required.   

Review of Policies, Procedures and Guidelines

All infection control policies and protocols are reviewed and have been updated this year. All policies are linked to online training and staff are required to undertake the training annually.

Policies/protocols are detailed below:

  • The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections.
  • Guidelines for Safe Working Practice
  • Access to Occupational Health
  • Biological substances Incident protocol
  • Cleaning Plan
  • Clinical Waste Protocol
  • Contagious Illness Policy
  • Decontamination Training, Policy and Register
  • Disposable Instruments Policy
  • Hand Hygiene Policy
  • Hepatitis B policy
  • Infection Control Incident Protocol (Spillage)
  • Infection Control Inspection Checklist
  • Infection Control Policy
  • Laundering of Uniforms
  • Legionella Policy
  • Needlestick Injury policy (Sharps)
  • Personal Protective Equipment (PPE) policy
  • Patient Isolation Policy
  • Staff Screening and Immunisation Policy
  • Specimen Handling Policy

Harriet Shaw, Infection Control Lead

May 2019